Provider Demographics
NPI:1356613996
Name:BERTHELSEN, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:BERTHELSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 GALILEE LN
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-9002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 58TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4814
Practice Address - Country:US
Practice Address - Phone:970-356-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-28
Last Update Date:2012-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant